HomeMy WebLinkAboutApplication and WC TOWN OF YARMOU2H�OARD OF HEALTH
APPLICATION FOR LICENSE/PERMIT-2017
*Please complete form and auach all nec�sary documents by _ �,��.
' Failure to do so will result in the return of your applicat�on pac ,t,
" ESTABLISHMENT NAME: D
I.C?CATION ADDRESS: _ Q � TEL.# cP
MAILING ADDRESS: �
E-MAIL ADDRESS:
OWNER NAME:
� CORPORATION NAME(IF PLIC L ):__. �i
MANAGER'S NAME: O � TEL.#: �/ d
MAII.TNG ADDRESS•
POOL CERTIFICATIONS:
The pool aapervisor maat be artiSied as a Pool Operntor,�a required by Stat�law. Please list the d�signated
Pool Operator(s)and attach a c�py of the certification to this form.
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Pool operators must Iist a minimwn of two employees cwrentty certified in standarci First Aid aad Community
CardiapuLnonary Resuscitati�(CPR),having one certiSed employee on piemises at all times. Pl�list the
employees below and attach copics of th�cir c.ertifications w this fotm.The He�Departm�t wW not me past
yw�s'records. YoH ast pr+nvide aew d iatain s$k�tt youur plsee of bq�iuess
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FOOD PROTECTION MANAGERS-CERTIFICATIONS: �j ►v ,.E
Ail food service establiahments are requirod to have at least one full-time�nployee who is certified as a Foad �� a �'
Protection Menager,as definai in the State Sanit�ry Code for Food 5ervice Fstablishm�ents, 105 CMR 590.000. �� � �a'.�;;
Please attach copies of ceatific•.s#ion to this application_ The Healt6 Departmeet w�t not ese p�st ye�s'reearda
Yoe mast provide aew eopies and maintaia a IIe st yo�r estsbW�en� �-----�.�
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PERSON tN'CT-IARGE: ,,
Each food establishment mest havcat kastrnie Person In C�rge(PIC)on site�wing l�s:of a�d�tt.
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.s�t.LERGEN CERTIFICATTONS: " �
All food servicx estabiishments ae+e requinad ta have at least one fWl-time employee who has Allergen certification, `Q� ''
as defined in ttye State Sanitary Code for Food Service Establishmems,105 CMR 590.00Q{G�3xa). Please attach
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c�pies of c�fication to this applicarion. The H�Depsrtmeut�vill aot uae past yeara'rceee�ds. Yoe must � '
provide nc7v eapies and maiat�ia��e at yoar�sstitblishmen�
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HEIIuILICH CERTIFTCATTONS:
All food service establishments with 25 seats oz moze must have at least ane employce trained in ihe Heimlich '
Maneuver on the premise.s at all times. Plea�list}roure�p layces trained in ami-choking pra�edures below and I
attach copies of employee certifications ta this form. T6e�Haath Departmeat w�i aot me paat pears'recorda.
Yam m�st r+�vid�new�pks and maietain t Sle at yonr place af bnsiness.
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RESTAURANT SEATING: TOTAL#
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OFFICE USE ONLY I
Lo�cnvc: ;
LICENSE REQi1IRED FEE PERMTf# L[CENSE REQ111RfiD FEE PERMIT# LI SE REQUIIt�b FEE P !1 �
� S55 CABB'1 S55 U7'EI- St 10 ��
—lNN S55 GAMP SSS SWIi�ffNlNG POdL S118ea.
=LODQE T55 �IRAILER PARK S105 =WH[RI,POOL TI l0ea.
F�OOD 3ERYICE:
LIGENSE FEE PERMiT# LICENSE REQUIRED FEE EFit�it L[CEN3E UIRFFI? F�E PERMlT N
aeao s� sizs co�rrna�rr,�, sss i
�>ioa se,�rs s2ao "`�`co�or�v�c. sso ���� -�o� �
RETAIL SERV[G'E:
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LIGENSE REQLJRtFA EEE pERM17'f� LICENSS REQUtRED FEE PERMIT# LICENSE REQUIRED FEE PERMff# !
_CSOsq.8. SSO >25 000sq�a. SZ85 YENDING-FUOD i23
43,000 sq.ft. S150 =FRa7.�1VV DESSERT S40 ='['OBACCO SI 10
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PtAA�ECHANGE: St5 ,�jdjj�ij'j'��i c s
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.�:.:PLEASE TCJRN OVER XND COMPLETE OTHER SIDL OF F(iRM••:+•
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ADMINISTRATION
Under Chapter 152,Secrion 25C,Subsection 6,the Tawn of Yarmouth is now required to�ld issusnce or�al ,
. of any license or permit to opeiats a business if a person or campany daes not have a Ceriificate af Worker's ',
Comgensation Insurance. THE ATTACHED STATE WORI�R'S COMPENSATION INSURANCL '
AFFIDAVTT MUST BE COMPLETED AND SIGNED,OR
CERT.OF INSURANCE ATTACHED
OR
I WORKER'S GOMP.AFFIDAYIT SIGNED AND ATTACHED
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Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of yvur petmits. PLEASE CHBCK
APPROPRIATELY�PAID: /
YES ✓ NO
MOTELS AND OTHER LODGING ESTABLI3HIMiENTS
TRANSIENT O��UPANCY: For purposes of the Wnitations of Motel or Hotel use,Transie�t accupnncy shall be
limited to the temporary aad short term occuP�ncY,ordinarily amd customazily associatsd witlt motel a�hotel u�.
Transient occupants must have and be able to demonstrate that they maintain a princi�i place of residence
elsewhere.Tr�sieni occupancy shall genetally refer to continuovs axupancy ofnot more t�aathirty(30)days,and
an aggregate of�t more that►ni�ty(90)days within any six(�month period. Use ofa guest unit as a resideace�
dwelling unit shall�t be considered transient Occupancy that is subject to the�llection of Room Occupancy
Excise,as rkfined in M.G.L.c.64G or 830 CMR 64G,as amended,shall generaily be consi�red Transient.
POOLS
POOL OPENING:All swimming,wading and is which�been`�clo�d for tt�seasom must be inspected
by the Health Department pnor to openwg. Contac�tlhe Health��eut to a�c�edule�e inspecNon tLree C3)
����P�,�E NOTE:People are NOT allo w sit in the pool azea until the pool l�as been
PQOL WATER Z'FS1'�1VG: The water must be tested far pse�domonas,total coliform and standac+i plate co�mt ;
by�c.ertified Iab,and submirted to tl�Health Deparhnem three(3)days p�iar to opening,and quaiterly
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POOL CLOSING:Every ontdoor in ground swimming pooi must be drained or covered witbm�ven(7�days of '�
closing.
FOOD SERVICE
SEASONAL FOOD SERVICE OPENII�TG:
Atl food service establishments must be inspected b�the Hwlth De�mrtment prior to opening. Please cont�ct the ;
Health Depar�t to sct�dule the inspect�on ttuee(3}days prior to openuig.
CATERING POLICY: '
Anyone who caters witbia the Towa of Yaimouth must norify the Yarmouth Heaith DeQartment by filing the
required Temporary Faod Service Apptication fotm 72 hours prior to the catered evenL These fo�ms can be '
obtamed at t�e Health D�part�nt,or from the Town's website at www.vam�ou�.ma.us�T�e�lth Depari�nt, '
Downloadable Forms. '
FROZEN DESSERTS: '
Froaen dessects mast be tested by a State certified lab prior to opening and monthly thereaft,er,whh sample r�ilt�
submitt�l to the f iealth Department. Failure to do so will result ia the suspcnsion or revocation of yout Frozen '
nessezt Permit imtil th�above terms have beea met.
OUTSIDE CAF�S:
Outside cafes(i.e.,outdoor seating wi�wait�lwaitress service�must have�or apgmval fivmtheBoac�ofHealih
i OUTDOOR COOI�I.NG:
i Oukdoor cookiug,preparatioq or display of any food product by a retail or food savice e�Gshment is proLibited. '
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NOTICT:Permits run atmually from Jaaoary 1 to De�ember 31. IT IS YOUR BFSPONSIBILITY TO RET[JRN
: THE COMPLETED ItENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 16,20i6. ?
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j ALL RENOVATTONS TO ANY' �'OOD ESTABLISH11+iFNT, MOTEL OR I'OOL {i.e., PAINT7NG, NEW I
� EQUIPMENT,ETC.),MUST BE REPORTEU TO AND APPROVED BY TI�BOARD�F HEAL.TH PRIOR I
� TO CO�NCEMENT. RENOVATIONS MAY RE UIRE A S1TE PLAN.
DATE: SIGNATURE: : '
PRIN'T NAME&TITGE: — c S '
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� The Comnro�ewealtlk ofMassachusefts
Depart�next o�lndn.��rial Accider�s
O,f�ice of�r�►►est�gafio�r,s
, I CoRgress SYree�Suilc 1 AD
Boston,ll�! UZll�F?Al7
wrvw.r��.govldia ',
Workers' Compensation Insnraace Affids�vit: Genera!Bnsinesses
j Apptican��ormation Ple�se-P�'mt I,�iblv
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; BusineSslOrganization Name:
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' Aaa�s: �9� �� ��
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c�is�z�p: � �n�#: ��-a�- ��i-i9�f�'
�1r,.e_y,�oa aa employer' �eck tke aPP�Prixte boz: Bns�xe�TType(re4tired):
, 1.!� 1 am a lo er with la �s full and/ 5. Q Retail
, �PY � _� Y t
or part-time).* 6. ❑RestaurantYBar/Eating Establishment
2.❑ I am a sale proprietor or partnership and have no 7. ❑p������{incl.real estate,auto,etc.}
ecnployee,s wor�Cing for me in any capecity
[Na work�rs'comp.insura�nce iequired] 8. ❑Non-profit
3.❑ We are a corporation and its officers havo e�cise� 9. ❑Et►t�tainment
their right of exemption per c. 152y§1(4�a11d we have 10.�Mstltlfaotutin$ '
no employees.(No workers'comp.inseu�ance requit+ed)*
4.❑ We are a non-profit organization,staffed by voluntee�s, I I.Q Heahi�t;are
wi#h no employees.(No workers'camP-�i''�9-J 12-t�rmer /J7D��
•nuy,q�plicmc ihar c�edcs box#1�sc also Hn o�n me�btbw sa,o.vmg thea worloa�s'ooa�on pdicy infa�matiaa•
sslf ifie coaporaEe oP�s have e�cemproed�elves,but the oo�pore�ion has otha�eGs,a wncloas'�a�ion Pdicp is roqu�+ed�d�dt an
' shoukl dfedt bou#L '
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I mat an a�loyu that�s prnvldt�g workets'ann�n�itsrtCroy�e.fnr rnY tntPlo,}uoe� Below ts tlie p�oUsy�ieform�et�3ri�e.
Insurance Cflmpany Name: �S' :D �
Inaurrx's Add�ss: . �� . � C�C�c� ;I
�����n�c���/o �`�-�,�.�����������- .
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Policy#or Self-ins.L"ec.# , , ' 'aa Date:
Att�ch s oopy of the�rorkera'eoffipe�ts�ttio�policy+decl�rntion 1�atge(�owi,g t�e paFlicy an�ber agd ' tioe da��.
Failure to secuee coverage as e�aquired un�r Section 25A of MGL c. 152 caa le�d to die impositicxt of criminal p�nalties of a 4
fine cip to S1,SOO.UO andlor aie-year im�nisonmec�t,as well as civil penaliies in tbe form of a STOP�VORK ORDER aad a fne j
of�to 5250.40 a day against ti�violator. Be advised tbat a oopy of this stateme�t may be forwarded to the Office of :
Ynvestigations of the DIA for ins�rance covet�age veriftcation.
I do hereby certify,under the pa�nx and ofpa,�rrr�►thet t6e irefor�tlrin provided�rbmne�s trrte ar�co�re�
� Dat�:� —�� � I
�onc#_ C�,� �7/�9e� I
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O,f 9cfat use onl�. Do,urt wri�ir�thi�maa,to I�t±�t�ated bp citj►or tow�a,,�cf� �
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Cyty or Towa: PetmitlLfice�e# f
Iaanir�g Ant�ority(circle one):
l.Boaesd of Heatth 2.Baildia�Depa�rta�e�t 3,�itylTowa Ct�k 4�.Licenaiag Bostd 5.Selec�r�sn'a Offioe
6.Ot�
Coatact Person: Phone#:
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TRAVELERS,w` WORKERS COMPENSATtON
AND
EMPLOYERS LIABILITY POLlCY
, EXTENSION OF INFO PA('E-SCHEDULE WC 00 00 01 ( A)
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! POUCYNUMBER: (7PJlt6-2E194o0-s-is)
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INSURER: TRAVELERS PROPERTY CASUA�TY CONpANY OF A►�RIGA
13579-MA
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INSURED`S NAME : YARNIOUTH GARDENS INC
RATE BUREAU ID: 000078667
PREMIUM BASIS
ESTIiaATED RATES ESTIMATED
TOTAL A�pol1AL RER $100 OF AIWVUAL
CLASSIFICATION C�E REMUN�RATION RENAl1�RATIQN PREMIUM
LOCATION 001 01
FEIN ENTITY CD OOi
YARMOUTH GARDENS INC
497 MAIN STREET
WEST YAR(�UTH. MA 02673
S I C CODE : 7011 NAI CS: 72i 199
C�ERICAt QFFICE ElM�LOYffS _ _ _- --- - ___ _--
_�_. ___ _ _ __
NOC 8810 IF ANY .08
i-107EL: ALL OTHER EN�LOYEES &
SALESRERSONS, BRIVERS 9052 20800 1 .58 329
HOTEL: RESTAURANT EMPLOYEES 9058 If ANY t .58 '
MERIT RATIN6/EXPERIEI�E iNOp: I�iVE 1M[3pIFIED PREMItNN $ (�� �
L�SS C�ISTANT 20
TOTAL ESTIMATED At�JAL STA(�ARD PREMIUM 329
EXPENSE CONSTANT(0900) 250
0.0300 TERRORISM (9740) g
5.75% MA WC SPECIAL FIJPD ANp TRUST FU1� 1 g
TOTAL ESTIMATED PREMIUM 624
DEPOSIT AP�OUNT DUE �24 �
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DATE OF ISSUE: 07-22-16 N�-f ST ASSI6FV: MA SCHEDULE NO: 1 OF LAST
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